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Capturing patient information is a critical
stage of the healthcare process.
The methods chosen to do so
can affect everything from the
amount of time a physician spends
with a patient to the accuracy
of the health record created
from the information collected
and to the availability and
value of that information to
subsequent healthcare providers.
As the healthcare community
more universally incorporates
the use of electronic medical
records and moves toward e-care,
the number and methods of information
capture are expanding. These
options stimulate debate about
whether or not to transition
to a new form of patient documentation
– and if so, which one
– or to continue to use
traditional methods, most commonly
medical transcription. This
article will focus on medical
transcription in relationship
to electronic medical records
(EMRs)
When considering information
capture choices, practitioners
and administrators must carefully
consider not just current needs
but also future goals. Depending
on the size, style, and type
of facility, requiring a single
information capture method could
result in additional costs or
lead to savings of millions
of dollars in a hospital. It
could attract physicians or
make a hospital unpopular with
doctors. The typical conclusion
is: Let doctors use any method
they want to use, while offering/encouraging
adoption of methods that facilitate
point-of-care and real-time
documentation. Traditional medical
transcription continues to be
the choice of many physicians,
especially among those who have
routinely been using this form
of documentation throughout
their career, but is it the
best choice for healthcare?
And if it is, for how long will
it continue to be?
Nationwide, transcription
is a huge industry. Medical
Records Institute estimates
that 90% of information capture
is dictation and transcription,
compared with less than 3% front
end speech recognition and about
6% direct physician input by
keyboard, stylus, touch screen
and other methods. (New technologies
such as digital pen have almost
no impact at this time [1% or
less].) While no hard figures
exist on the size of the transcription
industry, AHDI (Association
for Healthcare Documentation
Integrity – formerly AAMT,
the American Association for
Medical Transcription) reports
that “current global medical
transcription service expenditures
are estimated between $12 billion
and $20 billion annually, with
the United States being the
largest market.”1 (Estimates
in past years ranged as high
as $28 billion for the US market
alone.) The medical transcription
industry, populated by a few,
very large corporations, a wide
range of small to large businesses
and cottage industry outlets,
and innumerable solo contractors,
is a very private industry,
one that has neither routinely
nor widely shared statistical
information about its operations
and finances, which at least
partly explains the great disparity
and uncertainty in estimates.
Further, it’s only in
recent years that the healthcare
industry in general has closely
examined the costs of documentation,
perhaps stimulated by the move
toward EMRs and the concomitant
increasing awareness that information
capture is the key to EMR success.
Another way to estimate the
size of the transcription industry
is to survey the number of documents
dictated and assess how many
transcriptionists would be needed
to transcribe these documents.
Estimates several years ago
indicated that the volume of
reports traditionally dictated
(including H&Ps, discharge
summaries, consultations, operative
reports, and radiology) would
require somewhere between 300,000
and 400,000 medical transcriptionists
(MTs) to transcribe them. This
contrasts significantly with
US Bureau of Labor Department
statistics in 2006 that reported
fewer than 100,000 employed
MTs, with projected employment
of 112,000 in 20162. Those figures
are likely incomplete as the
Bureau only recently began to
count MTs as a separate category,
and it will take time for respondents
to change their reporting habits
of including MTs among medical
records clerks, medical secretaries,
medical assistants, stenographers,
and other categories of employees.
If indeed these labor statistics
are accurate, they emphasize
a significant problem regarding
the demand for dictation compared
with the availability of employed
MTs. The integration of back-end
speech recognition with medical
transcription is helping to
meet this demand, as is offshore
transcription, but the latter
creates a range of reactions,
from relief that there are more
MTs somewhere – especially
when offshore transcription
charges less and offers overnight
turnaround – to concerns
for quality and security (the
latter including both security
of patient information and job
security for MTs).
What is
the Future of Medical Transcription?
Although visionaries of EMRs
and EHRs (electronic health
records) have been predicting
the demise of medical transcription
for almost 20 years, all have
been proven wrong. While in
the ambulatory sector, paperless
EMRs have reached an estimated
15% to 20% level of adoption,
hospitals are in the high nineties
as they maintain transcription
and paper parallel to electronic
records. This duality represents
a financial burden but is considered
appropriate legal protection
as many advisors do not consider
the computer data integrity
to be at the level of paper-based
documentation, and further,
some states do not yet recognize
the legality of electronic documentation
and/or signatures. As a result,
many providers facilitate the
creation of digital data on
computers and then waste its
potential benefits by printing,
sorting and assembling the documents,
then filing and maintaining
them in traditional medical
record charts. Further, they
copy, scan, or fax such documents
to make them available to various
users. We are not aware that
the costs of these duplicative,
wasteful activities have been
captured or reported, but estimates
range from under $100 million
dollars to billions of dollars,
considering the thousands of
hospitals and clinics and physician
practices still adhering to
these practices that perpetuate
medical transcription as it
was developed decades ago, even
while concurrently adopting
EMRs.
Transcription
and EMRs
With the slow but steady move
to electronic medical records,
two questions about medical
transcription emerge. First,
when will direct data entry
options have a significant effect
on medical transcription, and
second, what is medical transcription’s
role in the transition to EMRs
and computer-guided and computer-based
care?
Certainly, medical transcription offers
a bridge to EMR adoption, though
historically, the overwhelming
hope/desire among those administratively
responsible for patient documentation
has been that the EMR offers
the best opportunity yet to
get rid of transcription and
its concomitant headaches –
employment of a workforce that
requires training and supervision
and has high turnover as MTs
move from job to job and also
has huge costs, but that doesn’t
consistently deliver in terms
of quality and turnaround time.
So, the budding EMR industry
ignored the potential of transcription
as a catalyst for EMR adoption,
and the transcription industry
was too fragmented and overconfident
to recognize and respond quickly
to the changes and threats that
EMRs would bring. Had the transcription
industry been willing and prepared
early on to move toward integration
with EMR and had the healthcare
industry recognized the stimulus
that medical transcription could
bring to EMR adoption, they
could have jointly benefited
and advanced. Doing medical
transcription electronically
long preceded the first EMRs,
so that electronic documentation
would have been a natural and
simplistic starting point around
which to design EMRs. Unfortunately,
that embryonic EMR revolution
was aborted early on.
So, the question must be
asked, can medical transcription
still stimulate the EMR market?
Well, yes and no. For those
physicians who continue to choose
medical transcription as their
information capture method of
choice, the transcription industry
and EMR vendors should, even
must, be responsive. What can
be done? While health informatics
professionals complain about
the slow adoption of EMRs, the
transcription industry and the
EMR vendors should ramp up their
cooperation to create uniform
integration. Let every one of
the 300+ EMR systems allow dictation
and let the market determine
whether the related turnaround
time, quality, costs, etc. (see
below) are acceptable. Let users
dictate on cell phones and dictation
devices, or through laptops
and tablets—whatever their
preference. And start addressing
whether free text should be
limited and templates developed
that allow/push physicians to
dictate in structured or semi-structured
form. This too could have been
initiated years ago. Why wait
any longer?
| The inherent
concerns about medical transcription
voiced by many providers,
administrators, and executives
remain and must also be
addressed. |
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Huge
costs : Transcription
costs per physician range
from several thousand dollars
to $25,000 and more annually.
More and more physician
practices and healthcare
institutions are seeking
alternatives by experimenting
with back-end speech recognition,
introducing front-end speech
recognition, and using more
point-of-care documentation
devices and other technologies.
While the success of such
experiments is scattered,
they are expected to become
increasingly common. |
 |
The
demand for MTs exceeds the
supply. Hospitals and
clinics have trouble finding
qualified transcriptionists.
Rather than looking at the
alternatives of new technologies,
most are trying to solve
their shortages by outsourcing
transcription, which just
shifts the point of impact.
The integration of back-end
and front-end speech recognition
with medical transcription
is helping to meet this
demand, as is offshore medical
transcription, but as noted
above, resistance in some
quarters remains strong.
And, even with integrating
those alternatives, the
supply/demand problem remains. |
 |
The
shrinking MT population
: “The MT profession
is faced by the two-pronged
problem of an ageing population
without younger replacements.3 The Bentley
College study making this
observation reports that
46% of its MT respondents
are age 50 or more and
76% are age 40 or more,
leaving fewer than 25%
under 40. This ageing
trend started years ago
and shows no signs of
reversing. The industry
could simply die of old
age.
|
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Turnaround time (TAT): Documentation of patient status and
treatment should be immediately available to other healthcare professionals
who need to base further decision making on previous documentation. If such
information is not available due to transcription delays, the quality of care
is diminished and patients could be harmed. In an ideal world, dictated
information is immediately transcribed and available to other providers, but
traditional (and back-end speech recognition-supported) medical transcription
simply cannot meet the increasing expectations and value of this real-time
documentation. A recent study of TAT by the American Health Information
Management Association (AHIMA) and the Medical Transcription Industry
Association (MTIA) reports “that very few standards for performance currently
exist in the area of transcription TAT.”4 Noting that there is no precise TAT definition,
the study chose what it identified as a widely held definition: “TAT for
transcribed reports is the elapsed time from completion of dictation to the
delivery of the transcribed document either in printed medium or
electronically to a repository.”5 The AHIMA/MTIA study reported on separate
surveys of HIMs (health information managers) and managers of MT/MTSO (medical
transcription/medical transcription service organizations). The HIM survey
reported that their contracted for and expected TATs for both paper and
electronic documents range from 24 hours (for H&Ps, operative reports,
consultations, progress notes, and pathology and cardiology reports) to 48
hours for paper discharge summaries and 48 to 72 hours for electronic output
(!!). The MT/MTSO respondents reported similar TATs for paper documents, i.e.,
21 to 40 hours for the same reports noted above, with radiology reported
separately at 12 hours. When limited to electronic reports, the range improved
to 18 to 35 hours, with radiology, again reported separately, having the best
TAT at 10 hours.6 Of course, it should be acknowledged that many
providers have digital dictation systems that allow access to the stored voice
dictation during TAT, but this can create problems, particularly if the
originator is difficult to understand, leading to the potential that different
listeners may interpret and act on the dictation differently—with little or no
documentation other than the voice file to back up what a particular listener
heard. This means that, if the dictation is accessed by someone other than the
originator and used even in part as the basis for patient care decisions and
treatment, then that voice file must identify who accessed it when and must be
preserved as part of the patient record, making it discoverable should there
be legal action requiring that the patient’s record be produced. While the
TATs reported in the AHIMA/MTIA study represent improvements over past
transcription TAT performance (which sometimes extended to days, even weeks),
they don’t meet the need (sometimes demand) for real-time, point-of-care
documentation. Thus, alternative options that facilitate such documentation –
front-end speech recognition, direct data entry via keyboard, pull-down lists,
touch and click, etc. – are increasingly attractive. Some physicians are
choosing to use scribes in exam rooms, presenting a career transition
opportunity for MTs. As scribes, MTs (or others) do direct, real-time entry of
patient information into EMRs as physicians “dictate” their findings and
assessments during or immediately following patient encounters. While none of
these alternatives represent an immediate threat to the medical transcription
industry, it would be a mistake to dismiss them as unrealistic and not worthy
of serious attention by the industry. |
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Control and access : At least somewhat related to turnaround time
are issues of control and access. Electronic dictation/transcription
developments are partially addressing this problem, for example, by allowing
access to voice files and transcription in process (which raises the concerns
expressed in the previous section), but originators are still left with
adjusting to the transcription industry’s limitations rather than having
immediate access and control of their documentation, which real-time,
point-of-care documentation options give them.
MRI’s 2007 Survey of EMR
Trends & Usages cited the following factors as most driving the need for
EMR systems in medical practices |
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Improved patient documentation |
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Efficiency and convenience to physicians through workflow benefits |
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Remote access to patient information |
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Transcription quality : Whatever the real numbers of MTs, the
range of their abilities, like those for any profession, varies from poor to
excellent, resulting in work products with a similar range of quality. Some
years ago, when the author was CEO of the American Association for Medical
Transcription—now the Association for Healthcare Documentation Integrity—a Hay
Management Consultants study identified three levels of MTs, with level 3 MTs
having the most expert depth and breadth of professional experience and
serving as a resource to originators, other MTs, other healthcare providers,
and students8 The author estimates that less than 20% of the
MT population meets this level 3 definition. Supporting this view is the
reality that, 25 years after the introduction of MT certification, there are
fewer than 4000 CMTs (certified medical transcriptionists) even though
eligibility for the certification exam (which is offered by AHDI) requires
only two years of experience as an MT in an acute care setting. Further
support is demonstrated in the recent statement from MTIA strongly advocating
professional credentialing in response to the “need to promote the role of a
highly skilled knowledge worker”9 in healthcare documentation and suggesting that
when seeking level 2 transcriptionists, employers should indicate that
certified status be required or preferred. (An RMT (registered medical
transcriptionist) credential is recommended for entry level, or level 1,
transcriptionists.) Notably, the MTIA statement does not speak to recruiting
level 3 MTs, nor indeed is there a professional credential aimed at level 3
MTs. Finally, the quality of medical transcription has long been of concern in
the healthcare industry, and indeed was a major factor behind the hope that
EMRs would lead to better quality solutions. In fairness, however, quality
deficits attributable to the originator who dictates patient documentation
must also be acknowledged, including mumbling, rambling, excessive speed,
background noises (music, bathroom, family, traffic, etc.), mispronunciations,
wrong words, to name the most obvious and common. |
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